Crystal Structures of YkuI and Its Complex with Second Messenger Cyclic Di-GMP Suggest Catalytic Mechanism of Phosphodiester Bond Cleavage by EAL Domains

Cyclic di-GMP (c-di-GMP) is a ubiquitous bacterial second messenger that is involved in the regulation of cell surface-associated traits and the persistence of infections. Omnipresent GGDEF and EAL domains, which occur in various combinations with regulatory domains, catalyze c-di-GMP synthesis and degradation, respectively. The crystal structure of full-length YkuI from Bacillus subtilis, composed of an EAL domain and a C-terminal PAS-like domain, has been determined in its native form and in complex with c-di-GMP and Ca²⁺. The EAL domain exhibits a triose-phosphate isomerase-barrel fold with one antiparallel β-strand. The complex with c-di-GMP-Ca²⁺ defines the active site of the putative phosphodiesterase located at the C-terminal end of the β-barrel. The EAL motif is part of the active site with Glu-33 of the motif being involved in cation coordination. The structure of the complex allows the proposal of a phosphodiesterase mechanism, in which the divalent cation and the general base Glu-209 activate a catalytic water molecule for nucleophilic in-line attack on the phosphorus. The C-terminal domain closely resembles the PAS-fold. Its pocket-like structure could accommodate a yet unknown ligand. YkuI forms a tight dimer via EAL-EAL and trans EAL-PAS-like domain association. The possible regulatory significance of the EAL-EAL interface and a mechanism for signal transduction between sensory and catalytic domains of c-di-GMP-specific phosphodiesterases are discussed.The dinucleotide cyclic di-GMP (c-di-GMP) was discovered about 20 years ago when it was found to regulate the activity of cellulase synthase in Acetobacter xylinum (1). However, its prominent role as a global second messenger has been realized only upon the recent recognition of the omnipresence of genes coding for domains that catalyze c-di-GMP biosynthesis and degradation in eubacteria (2). GGDEF domains catalyze the condensation of two GTP molecules to the cyclic 2-fold symmetric dinucleotide (diguanylate cyclase activity (3-6)), whereas EAL domains are involved in its degradation to yield the linear dinucleotide pGpG (phosphodiesterase (PDE)⁴ A activity) (3, 7-9). Recently, also HD-GYP domains have been implicated in c-di-GMP-specific PDE activity (10). All the domains have been named according to their sequence signature motifs. They are typically found in combinations with various other, mostly sensory or regulatory, domains. It is thought that the balance between antagonistic diguanylate cyclase and PDE-A activities determines the cellular level of c-di-GMP and, thus, affects a variety of physiological processes in bacteria.It has been shown that, in general, c-di-GMP regulates cell surface-associated traits and community behavior such as biofilm formation (for reviews see Refs. 11-12), and its relevance to the virulence of pathogenic bacteria has been demonstrated (11, 13, 14). In particular, the dinucleotide has been proposed to orchestrate the switch between acute and persistent phase of infection.The best characterized diguanylate cyclase is PleD from Caulobacter crescentus with a Rec-Rec-GGDEF domain architecture (Rec indicates response regulator receiver domain). The structure of its GGDEF domain revealed a single GTP-binding site and suggested that dimerization is the prerequisite for enzymatic activity (4). This has been corroborated recently by crystallography showing directly that modification of the first Rec domain, mimicking phosphorylation by the cognate kinase, induces formation of a tightly packed dimer (15). Additionally, an upper limit of c-di-GMP levels in the cell seems to be ensured by potent allosteric product inhibition of the PleD cyclase (4, 15, 16). Recently, the crystal structure of another diguanylate cyclase, WspR from Pseudomonas aeruginosa with a Rec-GGDEF domain architecture, has been determined (17), which showed a tetrameric quaternary structure and active and feedback inhibition sites that are very similar to those in PleD.For EAL domains, it has been demonstrated that genetic knock-out results in phenotypes that are in line with the paradigm that an elevated cellular c-di-GMP concentration corresponds to a sessile and a low concentration to a motile bacterial life style (13, 18, 19). Only recently, EAL-mediated PDE-A activity has been measured in vitro (7-9, 20-22).The Bacillus subtilis YkuI protein was targeted for structure determination by the Midwest Center for Structural Genomics as a member of the large sequence family that contains EAL (Pfam number PF00563) domains. Here we report the crystal structure of YkuI showing the fold of the N-terminal EAL domain and the C-terminal PAS-like domain. Co-crystallization with c-di-GMP revealed the substrate binding mode and allows the proposal of a catalytic mechanism. The PAS-like domain most probably has regulatory function, which is discussed. Recently, another EAL structure has been deposited in the Protein Data Bank by the Midwest Center for Structural Genomics, the EAL domain of a GGDEF-EAL protein from Thiobacillus denitrificans (tdEAL; PDB code 2r6o). Comparison of the two structures suggests a possible regulatory mechanism.     

Identification and Characterization of a Phosphodiesterase That Inversely Regulates Motility and Biofilm Formation in Vibrio cholerae

Vibrio cholerae switches between free-living motile and surface-attached sessile lifestyles. Cyclic diguanylate (c-di-GMP) is a signaling molecule controlling such lifestyle changes. C-di-GMP is synthesized by diguanylate cyclases (DGCs) that contain a GGDEF domain and is degraded by phosphodiesterases (PDEs) that contain an EAL or HD-GYP domain. We constructed in-frame deletions of all V. cholerae genes encoding proteins with GGDEF and/or EAL domains and screened mutants for altered motility phenotypes. Of 52 mutants tested, four mutants exhibited an increase in motility, while three mutants exhibited a decrease in motility. We further characterized one mutant lacking VC0137 (cdgJ), which encodes an EAL domain protein. Cellular c-di-GMP quantifications and in vitro enzymatic activity assays revealed that CdgJ functions as a PDE. The cdgJ mutant had reduced motility and exhibited a small decrease in flaA expression; however, it was able to produce a flagellum. This mutant had enhanced biofilm formation and vps gene expression compared to that of the wild type, indicating that CdgJ inversely regulates motility and biofilm formation. Genetic interaction analysis revealed that at least four DGCs, together with CdgJ, control motility in V. cholerae.Cyclic diguanylate (c-di-GMP) is a ubiquitous second messenger in bacteria. It is synthesized by diguanylate cyclases (DGCs) that contain a GGDEF domain and is degraded by phosphodiesterases (PDEs) that contain an EAL or HD-GYP domain (46, 48, 50). The receptors of c-di-GMP, which can be proteins or RNAs (riboswitches), bind to c-di-GMP and subsequently transmit the signal to downstream targets (22). C-di-GMP signaling is predicted to occur via a common or localized c-di-GMP pool(s) through so-called c-di-GMP signaling modules harboring DGCs and PDEs, receptors, and targets that affect cellular function (22).C-di-GMP controls various cellular functions, including the transition between a planktonic lifestyle and biofilm lifestyle. In general, high concentrations of c-di-GMP promote the expression of adhesive matrix components and result in biofilm formation, while low concentrations of c-di-GMP result in altered motility upon changes in flagellar or pili function and/or production (reviewed in reference 25). C-di-GMP inversely regulates motility and biofilm formation by implementing control at different levels through gene expression or through posttranslational mechanisms (reviewed in reference 25).Vibrio cholerae, the causative agent of the disease cholera, uses c-di-GMP signaling to undergo a motile-to-sessile lifestyle switch that is important for both environmental and in vivo stages of the V. cholerae life cycle. The survival of the pathogen in both natural aquatic environments and during infection depends on the appropriate regulation of motility, surface attachment, and colonization factors (26). The V. cholerae genome encodes a total of 62 putative c-di-GMP metabolic enzymes: 31 with a GGDEF domain, 12 with an EAL domain, 10 with both GGDEF and EAL domains, and 9 with an HD-GYP domain (21). V. cholerae contains a few known or predicted c-di-GMP receptors: two riboswitches (53), five PilZ domain proteins (43), VpsT (31), and CdgG (6). C-di-GMP regulates virulence, motility, biofilm formation, and the smooth-to-rugose phase variation in V. cholerae (6, 8, 9, 12, 30, 33, 43, 45, 54, 56, 57). However, particular sets of proteins have not been matched to discrete cellular processes.Some of the DGCs and PDEs involved in regulating motility in V. cholerae have been identified: rocS and cdgG mutants exhibit a decrease in motility (45), while cdgD and cdgH mutants exhibit an increase in motility (6). In addition, VieA (PDE) positively regulates motility in the V. cholerae classical biotype but not in the El Tor biotype (7). AcgA (PDE) positively regulates motility at low concentrations of inorganic phosphate (42). In this study, we investigated the role of each putative gene encoding DGCs and PDEs in controlling cell motility. In addition to the already-characterized proteins CdgD, CdgH, and RocS, we identified two putative DGCs (CdgK and CdgL) that negatively control motility and a putative PDE (CdgJ) that positively controls motility. We further characterized CdgJ and showed that it functions as a PDE and inversely regulates motility and biofilm formation. Genetic interaction studies revealed that DGCs CdgD, CdgH, CdgL, and CdgK and PDE CdgJ form a c-di-GMP signaling network to control motility in V. cholerae.     

Erythropoietin Receptor (EpoR) Agonism Is Used to Treat a Wide Range of Disease

The erythropoietin receptor (EpoR) was discovered and described in red blood cells (RBCs), stimulating its proliferation and survival. The target in humans for EpoR agonists drugs appears clear—to treat anemia. However, there is evidence of the pleitropic actions of erythropoietin (Epo). For that reason, rhEpo therapy was suggested as a reliable approach for treating a broad range of pathologies, including heart and cardiovascular diseases, neurodegenerative disorders (Parkinson’s and Alzheimer’s disease), spinal cord injury, stroke, diabetic retinopathy and rare diseases (Friedreich ataxia). Unfortunately, the side effects of rhEpo are also evident. A new generation of nonhematopoietic EpoR agonists drugs (asialoEpo, Cepo and ARA 290) have been investigated and further developed. These EpoR agonists, without the erythropoietic activity of Epo, while preserving its tissue-protective properties, will provide better outcomes in ongoing clinical trials. Nonhematopoietic EpoR agonists represent safer and more effective surrogates for the treatment of several diseases such as brain and peripheral nerve injury, diabetic complications, renal ischemia, rare diseases, myocardial infarction, chronic heart disease and others.In principle, the erythropoietin receptor (EpoR) was discovered and described in red blood cell (RBC) progenitors, stimulating its proliferation and survival. Erythropoietin (Epo) is mainly synthesized in fetal liver and adult kidneys (1–3). Therefore, it was hypothesized that Epo act exclusively on erythroid progenitor cells. Accordingly, the target in humans for EpoR agonists drugs (such as recombinant erythropoietin [rhEpo], in general, called erythropoiesis-simulating agents) appears clear (that is, to treat anemia). However, evidence of a kaleidoscope of pleitropic actions of Epo has been provided (4,5). The Epo/EpoR axis research involved an initial journey from laboratory basic research to clinical therapeutics. However, as a consequence of clinical observations, basic research on Epo/EpoR comes back to expand its clinical therapeutic applicability.Although kidney and liver have long been considered the major sources of synthesis, Epo mRNA expression has also been detected in the brain (neurons and glial cells), lung, heart, bone marrow, spleen, hair follicles, reproductive tract and osteoblasts (6–17). Accordingly, EpoR was detected in other cells, such as neurons, astrocytes, microglia, immune cells, cancer cell lines, endothelial cells, bone marrow stromal cells and cells of heart, reproductive system, gastrointestinal tract, kidney, pancreas and skeletal muscle (18–27). Conversely, Sinclair et al.(28) reported data questioning the presence or function of EpoR on nonhematopoietic cells (endothelial, neuronal and cardiac cells), suggesting that further studies are needed to confirm the diversity of EpoR. Elliott et al.(29) also showed that EpoR is virtually undetectable in human renal cells and other tissues with no detectable EpoR on cell surfaces. These results have raised doubts about the preclinical basis for studies exploring pleiotropic actions of rhEpo (30).For the above-mentioned data, a return to basic research studies has become necessary, and many studies in animal models have been initiated or have already been performed. The effect of rhEpo administration on angiogenesis, myogenesis, shift in muscle fiber types and oxidative enzyme activities in skeletal muscle (4,31), cardiac muscle mitochondrial biogenesis (32), cognitive effects (31), antiapoptotic and antiinflammatory actions (33–37) and plasma glucose concentrations (38) has been extensively studied. Neuro- and cardioprotection properties have been mainly described. Accordingly, rhEpo therapy was suggested as a reliable approach for treating a broad range of pathologies, including heart and cardiovascular diseases, neurodegenerative disorders (Parkinson’s and Alzheimer’s disease), spinal cord injury, stroke, diabetic retinopathy and rare diseases (Friedreich ataxia).Unfortunately, the side effects of rhEpo are also evident. Epo is involved in regulating tumor angiogenesis (39) and probably in the survival and growth of tumor cells (25,40,41). rhEpo administration also induces serious side effects such as hypertension, polycythemia, myocardial infarction, stroke and seizures, platelet activation and increased thromboembolic risk, and immunogenicity (42–46), with the most common being hypertension (47,48). A new generation of nonhematopoietic EpoR agonists drugs have hence been investigated and further developed in animals models. These compounds, namely asialoerythropoietin (asialoEpo) and carbamylated Epo (Cepo), were developed for preserving tissue-protective properties but reducing the erythropoietic activity of native Epo (49,50). These drugs will provide better outcome in ongoing clinical trials. The advantage of using nonhematopoietic Epo analogs is to avoid the stimulation of hematopoiesis and thereby the prevention of an increased hematocrit with a subsequent procoagulant status or increased blood pressure. In this regard, a new study by van Rijt et al. has shed new light on this topic (51). A new nonhematopoietic EpoR agonist analog named ARA 290 has been developed, promising cytoprotective capacities to prevent renal ischemia/reperfusion injury (51). ARA 290 is a short peptide that has shown no safety concerns in preclinical and human studies. In addition, ARA 290 has proven efficacious in cardiac disorders (52,53), neuropathic pain (54) and sarcoidosis-induced chronic neuropathic pain (55). Thus, ARA 290 is a novel nonhematopoietic EpoR agonist with promising therapeutic options in treating a wide range of pathologies and without increased risks of cardiovascular events.Overall, this new generation of EpoR agonists without the erythropoietic activity of Epo while preserving tissue-protective properties of Epo will provide better outcomes in ongoing clinical trials (49,50). Nonhematopoietic EpoR agonists represent safer and more effective surrogates for the treatment of several diseases, such as brain and peripheral nerve injury, diabetic complications, renal ischemia, rare diseases, myocardial infarction, chronic heart disease and others.     

Gut microbiota of healthy Canadian infants: profiles by mode of delivery and infant diet at 4 months

Background:

The gut microbiota is essential to human health throughout life, yet the acquisition and development of this microbial community during infancy remains poorly understood. Meanwhile, there is increasing concern over rising rates of cesarean delivery and insufficient exclusive breastfeeding of infants in developed countries. In this article, we characterize the gut microbiota of healthy Canadian infants and describe the influence of cesarean delivery and formula feeding.

Methods:

We included a subset of 24 term infants from the Canadian Healthy Infant Longitudinal Development (CHILD) birth cohort. Mode of delivery was obtained from medical records, and mothers were asked to report on infant diet and medication use. Fecal samples were collected at 4 months of age, and we characterized the microbiota composition using high-throughput DNA sequencing.

Results:

We observed high variability in the profiles of fecal microbiota among the infants. The profiles were generally dominated by Actinobacteria (mainly the genus Bifidobacterium) and Firmicutes (with diverse representation from numerous genera). Compared with breastfed infants, formula-fed infants had increased richness of species, with overrepresentation of Clostridium difficile. Escherichia–Shigella and Bacteroides species were underrepresented in infants born by cesarean delivery. Infants born by elective cesarean delivery had particularly low bacterial richness and diversity.

Interpretation:

These findings advance our understanding of the gut microbiota in healthy infants. They also provide new evidence for the effects of delivery mode and infant diet as determinants of this essential microbial community in early life.The human body harbours trillions of microbes, known collectively as the “human microbiome.” By far the highest density of commensal bacteria is found in the digestive tract, where resident microbes outnumber host cells by at least 10 to 1. Gut bacteria play a fundamental role in human health by promoting intestinal homeostasis, stimulating development of the immune system, providing protection against pathogens, and contributing to the processing of nutrients and harvesting of energy.^1,2 The disruption of the gut microbiota has been linked to an increasing number of diseases, including inflammatory bowel disease, necrotizing enterocolitis, diabetes, obesity, cancer, allergies and asthma.¹ Despite this evidence and a growing appreciation for the integral role of the gut microbiota in lifelong health, relatively little is known about the acquisition and development of this complex microbial community during infancy.³Two of the best-studied determinants of the gut microbiota during infancy are mode of delivery and exposure to breast milk.^4,5 Cesarean delivery perturbs normal colonization of the infant gut by preventing exposure to maternal microbes, whereas breastfeeding promotes a “healthy” gut microbiota by providing selective metabolic substrates for beneficial bacteria.^3,5 Despite recommendations from the World Health Organization,⁶ the rate of cesarean delivery has continued to rise in developed countries and rates of breastfeeding decrease substantially within the first few months of life.^7,8 In Canada, more than 1 in 4 newborns are born by cesarean delivery, and less than 15% of infants are exclusively breastfed for the recommended duration of 6 months.^9,10 In some parts of the world, elective cesarean deliveries are performed by maternal request, often because of apprehension about pain during childbirth, and sometimes for patient–physician convenience.¹¹The potential long-term consequences of decisions regarding mode of delivery and infant diet are not to be underestimated. Infants born by cesarean delivery are at increased risk of asthma, obesity and type 1 diabetes,¹² whereas breastfeeding is variably protective against these and other disorders.¹³ These long-term health consequences may be partially attributable to disruption of the gut microbiota.^12,14Historically, the gut microbiota has been studied with the use of culture-based methodologies to examine individual organisms. However, up to 80% of intestinal microbes cannot be grown in culture.^3,15 New technology using culture-independent DNA sequencing enables comprehensive detection of intestinal microbes and permits simultaneous characterization of entire microbial communities. Multinational consortia have been established to characterize the “normal” adult microbiome using these exciting new methods;¹⁶ however, these methods have been underused in infant studies. Because early colonization may have long-lasting effects on health, infant studies are vital.^3,4 Among the few studies of infant gut microbiota using DNA sequencing, most were conducted in restricted populations, such as infants delivered vaginally,¹⁷ infants born by cesarean delivery who were formula-fed¹⁸ or preterm infants with necrotizing enterocolitis.¹⁹Thus, the gut microbiota is essential to human health, yet the acquisition and development of this microbial community during infancy remains poorly understood.³ In the current study, we address this gap in knowledge using new sequencing technology and detailed exposure assessments²⁰ of healthy Canadian infants selected from a national birth cohort to provide representative, comprehensive profiles of gut microbiota according to mode of delivery and infant diet.     

Differential Interactions of Thrombospondin-1, -2, and -4 with CD47 and Effects on cGMP Signaling and Ischemic Injury Responses

Thrombospondin-1 regulates nitric oxide (NO) signaling in vascular cells via CD47. Because CD47 binding motifs are conserved in the C-terminal signature domains of all five thrombospondins and indirect evidence has implied CD47 interactions with other family members, we compared activities of recombinant signature domains of thrombospondin-1, -2, and -4 to interact with CD47 and modulate cGMP signaling. Signature domains of thrombospondin-2 and -4 were less active than that of thrombospondin-1 for inhibiting binding of radiolabeled signature domain of thrombospondin-1 or SIRPα (signal-regulatory protein) to cells expressing CD47. Consistent with this binding selectivity, the signature domain of thrombospondin-1 was more potent than those of thrombospondin-2 or -4 for inhibiting NO-stimulated cGMP synthesis in vascular smooth muscle cells and downstream effects on cell adhesion. In contrast to thrombospondin-1- and CD47-null cells, primary vascular cells from thrombospondin-2-null mice lack enhanced basal and NO-stimulated cGMP signaling. Effects of endogenous thrombospondin-2 on NO/cGMP signaling could be detected only in thrombospondin-1-null cells. Furthermore, tissue survival of ischemic injury and acute recovery of blood flow in thrombospondin-2-nulls resembles that of wild type mice. Therefore, thrombospondin-1 is the dominant regulator of NO/cGMP signaling via CD47, and its limiting role in acute ischemic injury responses is not shared by thrombospondin-2.Nitric oxide (NO) is a major mediator of intracellular and paracellular signal transduction. NO preserves vascular health by minimizing the adhesion of inflammatory cells to the vessel wall, limiting platelet activation, and increasing blood vessel diameter and blood flow by relaxing vascular smooth muscle cells (VSMC).³ These actions of NO are mediated by activating soluble isoforms of guanylate cyclase (sGC) to increase cGMP levels, resulting in downstream activation of cGMP-dependent protein kinases and ion channels (1).Physiological NO/cGMP signaling is limited by several phosphodiesterases that degrade cGMP and by thrombospondin-1 (TSP). TSP1 is a secreted protein that is produced by vascular and inflammatory cells that regulates cellular behavior by engaging several cell surface receptors. Recently we reported that TSP1 potently blocks NO-stimulated prosurvival responses in endothelial and VSMC (2, 3). TSP1 also plays a role in promoting platelet thrombus formation and hemostasis by antagonizing the antithrombotic activity of NO (4). In all of these vascular cells, picomolar concentrations of TSP1 are sufficient to block NO-stimulated fluxes in cGMP by engaging its receptor CD47 (5). Nanomolar concentrations of TSP1 further inhibit the same signaling pathway by inhibiting CD36-mediated uptake of myristate into vascular cells (6). In vivo, mice lacking TSP1 demonstrate elevated basal tissue cGMP levels and greater increases in regional blood flow in response to a NO challenge than wild type controls (4). After an ischemic insult, the absence of TSP1 or CD47 in transgenic mice is associated with better maintenance of tissue perfusion and enhanced tissue survival. Similarly, targeting TSP1 or CD47 using function blocking antibodies enhances ischemic tissue perfusion and survival in wild type mice and pigs (7, 8).TSP1 belongs to a family of five secreted glycoproteins that share an evolutionarily conserved C-terminal signature domain (9). TSP1 and TSP2 form a distinct subfamily of trimeric proteins that exhibit similar anti-angiogenic activities for endothelial cells in vitro and activities in vivo to block tumor growth. Despite their similarities in structure, TSP1 and TSP2 have markedly different expression patterns after tissue injury, with TSP1 being immediately expressed and maximal at day 3, whereas TSP2 was not expressed until day 7 and was maximal 10 days after injury (10). In addition, large amounts of TSP1 but not TSP2 are stored in platelet α-granules and released into the wound environment. Polymorphisms in TSP1 and TSP2 have been linked to altered risk of premature myocardial infarction (11, 12). A 3′-untranslated region polymorphism in TSP2 is also associated with type 2 diabetes in men (13). The molecular basis for these associations is unclear.Less is known about the roles of the pentameric TSP3–5 in vascular cells. TSP3 and TSP5 (also known as cartilage oligomeric matrix protein) appear to serve their primary functions in bone development (14, 15). However, a polymorphism in TSP4 is associated with premature myocardial infarcts in certain populations (11, 16, 17). A proatherogenic activity for the A387P variant of TSP4 was proposed based on its differential ability to modulate proliferation of endothelial and VSMC (18). Cardiovascular functions of TSP4 may also be linked to the high expression of TSP4 in heart (19) and its altered expression in that tissue during hypertensive heart failure (20).The C-terminal domain of TSP1 is sufficient to mediate CD47-dependent inhibition of cGMP signaling (5). Of the two CD47 binding VVM motifs identified in this domain of TSP1, the first is conserved among all five TSPs, suggesting that CD47 binding could be a universal attribute of this family (21). Based on structural evidence that the VVM motifs may not be accessible (22, 23), however, conservation of VVM motifs may not be sufficient to predict CD47 binding. Uncertainty regarding the location of the CD47 binding site in the G domain of TSP1 therefore limits interpretation of the known sequence homology to predict CD47 binding to other TSP family members.Although CD47 recognition of other TSPs has not been demonstrated experimentally, a local deficiency of inflammation-associated T cell apoptosis shared by TSP1-, CD47-, and TSP2-null mice is consistent with this hypothesis (24). Furthermore, a 21-residue peptide from the C-terminal domain of TSP4 was found to decrease human umbilical vein endothelial cell proliferation similar to the CD47 binding peptides from TSP1, although it lacks the VVM motif and no interaction with CD47 was demonstrated (25).To directly address whether other TSP family members can inhibit NO responses and signaling in vascular cells, we now compare binding of recombinant signature domains of TSP1, TSP2, and TSP4 to cell surface CD47 and inhibition of NO-stimulated cell responses and cGMP signaling by these domains. We also compared acute tissue blood flow and perfusion responses to ischemic challenge in TSP1 and TSP2-null mice and cGMP responses in primary cultures of vascular cells isolated from these mice. These studies clearly demonstrate that CD47 selectively interacts with TSP1 and that the signature domains of TSP2 and TSP4 are less potent inhibitors of NO signaling in vascular cells in vitro. Furthermore, we show that the role of TSP1 to acutely limit recovery from ischemic injury in vivo is not shared by TSP2.     

A qualitative investigation of smoke-free policies on hospital property

Background:

Many hospitals have adopted smoke-free policies on their property. We examined the consequences of such polices at two Canadian tertiary acute-care hospitals.

Methods:

We conducted a qualitative study using ethnographic techniques over a six-month period. Participants (n = 186) shared their perspectives on and experiences with tobacco dependence and managing the use of tobacco, as well as their impressions of the smoke-free policy. We interviewed inpatients individually from eight wards (n = 82), key policy-makers (n = 9) and support staff (n = 14) and held 16 focus groups with health care providers and ward staff (n = 81). We also reviewed ward documents relating to tobacco dependence and looked at smoking-related activities on hospital property.

Results:

Noncompliance with the policy and exposure to secondhand smoke were ongoing concerns. Peoples’ impressions of the use of tobacco varied, including divergent opinions as to whether such use was a bad habit or an addiction. Treatment for tobacco dependence and the management of symptoms of withdrawal were offered inconsistently. Participants voiced concerns over patient safety and leaving the ward to smoke.

Interpretation:

Policies mandating smoke-free hospital property have important consequences beyond noncompliance, including concerns over patient safety and disruptions to care. Without adequately available and accessible support for withdrawal from tobacco, patients will continue to face personal risk when they leave hospital property to smoke.Canadian cities and provinces have passed smoking bans with the goal of reducing people’s exposure to secondhand smoke in workplaces, public spaces and on the property adjacent to public buildings.^1,2 In response, Canadian health authorities and hospitals began implementing policies mandating smoke-free hospital property, with the goals of reducing the exposure of workers, patients and visitors to tobacco smoke while delivering a public health message about the dangers of smoking.^2–5 An additional anticipated outcome was the reduced use of tobacco among patients and staff. The impetuses for adopting smoke-free policies include public support for such legislation and the potential for litigation for exposure to second-hand smoke.^2,4Tobacco use is a modifiable risk factor associated with a variety of cancers, cardiovascular diseases and respiratory conditions.^6–11 Patients in hospital who use tobacco tend to have more surgical complications and exacerbations of acute and chronic health conditions than patients who do not use tobacco.^6–11 Any policy aimed at reducing exposure to tobacco in hospitals is well supported by evidence, as is the integration of interventions targetting tobacco dependence.¹² Unfortunately, most of the nearly five million Canadians who smoke will receive suboptimal treatment,¹³ as the routine provision of interventions for tobacco dependence in hospital settings is not a practice norm.^14–16 In smoke-free hospitals, two studies suggest minimal support is offered for withdrawal, ^17,18 and one reports an increased use of nicotine-replacement therapy after the implementation of the smoke-free policy.¹⁹Assessments of the effectiveness of smoke-free policies for hospital property tend to focus on noncompliance and related issues of enforcement.^17,20,21 Although evidence of noncompliance and litter on hospital property^2,17,20 implies ongoing exposure to tobacco smoke, half of the participating hospital sites in one study reported less exposure to tobacco smoke within hospital buildings and on the property.¹⁸ In addition, there is evidence to suggest some decline in smoking among staff.^18,19,21,22We sought to determine the consequences of policies mandating smoke-free hospital property in two Canadian acute-care hospitals by eliciting lived experiences of the people faced with enacting the policies: patients and health care providers. In addition, we elicited stories from hospital support staff and administrators regarding the policies.